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REV. 04/09/99 <br /> ' � SAN JOAQUIN COUNTY UBLIC HEALTH SERVICES B ENVIRONMENT, 1EALTH DIVISION <br /> MASTERFILE RECORD INFORMATION <br /> DATE OWNER ID 00 ODD <br /> OWNER FILE <br /> CHFC[6 OWNED CIIeeFNrt✓Ory FltE wid EHD ❑ <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: <br /> PnonE <br /> BwNfss owHFR N.u+E a y^ / lL� l ,_ ) I <br /> or <br /> asr l G / G- V <br /> /� 1� ,(J 1 Sac SFC/THx IDF <br /> prynFy�T / DIFFfR�V /GC/! N/ r -7 <br /> OwnEeHwEApoxss EJ�� +�� /' Y— <br /> C_ <br /> GN <br /> Z �CCJ �✓ C� <br /> AnFmXon:orcae d (OPXO^0O <br /> aWNERMNUNO ADDRss (YDIFffREM ham GWnfMAECreW <br /> SIOIR LP <br /> Mailing Al N:Z ON <br /> 1vM OF OwrY45Hv <br /> CORPORAPON t INDIVIDUAL PARTNERSHIP LOCAL AGENCY CO( AGENCY STATE AGENCY FED AGENCY OTHER t <br /> FACILITY FILE AZ <br /> FACILITY ID R P!11 <br /> UJ CROSS REF ID. ACCOUNT IDM DOU✓ID <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: <br /> glbrvfSs/FwCXM <br /> (r..1 M ME NM1IE Ori RIE HEALTH PERI. ) <br /> F E' .5 Cl� >7 C-t� <br /> SURE F EIwrIEss PwnF <br /> FACNn AoovFss as cc«nnSuar wooaFss Y l <br /> 16 <br /> 5*Ar. Lr '7 �L <br /> cm ov<orwwr-rsseFss oFm /�'"w� <br /> tb^m as SunevFwv Dumcl <br /> LOCAnoN CODE KhA NESS <br /> AnenXOn:w Care Or(Opawla0 <br /> HEALTH PERAIR MAIDNG ADDRESS(N DIfFFREM hom Fa<WN AOdrev) <br /> SATE m <br /> Mmllrp ACtlres+Gry <br /> sic CWf MN aCMMEM <br /> ACCWADQRf6E loffeesandCharges OWNER FACILITY/BUSINESS <br /> M <br /> IiILLING AND CONIlLIANCE ACKNOWLEDGMENT; 1, the undersigned Applicant, certify that I am the Owner, Operator, or <br /> Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or FLOURLY <br /> CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTADOR£.SS for this site. 1 <br /> also certify that all information provided on this application is true and correct; and that all regulated activities will he performed <br /> in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and S'rATE and/or FEDERAL Luws <br /> and Regulations. <br /> SIGNANPE <br /> ArMCAM NAME(Plow!IMI) <br /> „PLE PrP, <br /> App W BY D.f. A X 9 OM Pr esslnp CompleteG XY DateY <br />